Professional Documents
Culture Documents
Volume 3, Issue 2
How to Thrive in
Back to Basics: a Tough Economy
Electrosurgery
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The
OR Connection
Aligning practice with policy to improve patient care
24 Left Behind
Andy J. Mills, MBA, MWM
Contributing Editor
30 World Health Organization Issues Safety Checklist for
Surgical Teams
Mike Gotti
Art Director
37 Surgical Site Infections
Laura Kuhn
Copy Editor
43 Flipping the Switch on Pressure
46 Five Pressure Ulcer Factors to Keep in Mind Page 13
32 Moments of Truth
Gail Avigne, RN
Perioperative Advisory Board
54 A Place of Healing?
Shands Teaching Hospital (UFL), Florida
Caroline Copeland, RN MPH
58 Callie Craig: A Nurse Hero
Southern Hills Hospital & Medical Center 62 How to Thrive in a Tough Economy
Cathy Crandall, RN
HealthTrust Purchasing Organization, Tennessee
68 Angel’s Passion for Pink
Larry Creech, RN, MBA, CDT
71 Medline Supports Breast Cancer Awareness
Carilion Health System, Virginia 73 Recipe: Guacamole Page 24
Pat DʼErrico, RN, CNOR
Medical Center of Central Georgia, Georgia CARING FOR YOURSELF
Barbara Fahey, RN CNOR
Cleveland Clinic, Ohio
61 Building Unshakable Self-Confidence
Zaida Jacoby, RN, MA, M.Ed 72 Ease the Discomfort of PMS
NYU Medical Center, New York
Sherron Kurtz, RN, MSA, MSN, CNOR, CNAA FORMS & TOOLS
Wellstar Kennestone Hospital, Georgia 76 Electrosurgery Checklist
Wayne Malone, RN
Physicians Hospital, Texas
78 Electrosurgical Cautery Safety Page 32
Dear Reader,
Everyone agrees that preventing hospital- Then go to Page 86 in the Forms & Tools section,
acquired conditions can save thousands of lives where you can tear out a copy of the checklists for
and millions of dollars. This is the time to take your own use.
action. Hospitals across the country are implement-
ing new strategies. All of us are feeling the swell of But even with your checklist in hand, it might not be
change and the push back that comes with it. enough. That is why you should read through
Whether you are working with administration, mate- “Moments of Truth: How to enact a culture change at
rials management, your staff, physicians, vendors, your facility.” There are no miracles here, but a keen
consultants or your peers, the journey isnʼt and wonʼt understanding and expert guidance on how to create
be easy. Iʼve spoken to thousands of clinicians about a team that works together, problem-solves together,
the barriers they are facing when it comes to imple- helps each other out to give the patient the best
menting new policies and improving safety, quality care possible.
and patient satisfaction. Everyone wants to do
whatʼs right. The overwhelming things that we need Each of us contributes to the culture we work in, so
to make that happen are teamwork, communication,
education and – in many cases – additional
I was thrilled with Wolfe Rinkeʼs article “How to
Thrive in A Tough Economy” (Page 62). This article
“
This edition of
The OR Connection
resources. takes a closer look at how you can positively affect
is about bringing
your organization and your career in these times. positive change
This edition of The OR Connection is about bringing
positive change into your facility. One key solution Last, but certainly not least, this edition is chock-full
into your facility.”
that can help your patients receive a higher standard of safety updates and information. Thank you for
of care is the use of a checklist. I know if something being a part of the team. We look forward to visiting
is not on my list, there is a chance it will be forgotten. with you again in our next edition.
With the day-to-day pressure, interruptions and
stress that each of you must deal with in the OR, a Sincerely,
checklist might be just the right calming factor.
Checklists act as reminders to keep us on track, to
make sure weʼve covered everything we need to do. Sue MacInnes, RD, LD
Youʼll want to take a look at Page 30, where you will Editor
find the “Safety Checklist for Surgical Teams.” There
are three recommended checklists:
We've coded the articles and information in this magazine to indicate which patient
Content Key
care initiatives they pertain to. Throughout the publication, when you see these
icons you'll know immediately that the subject matter on that page relates to one
or more of the following national initiatives:
• IHI's 5 Million Lives Campaign
• Joint Commission 2007 National Patient Safety Goals
• Surgical Care Improvement Project (SCIP)
We've tried to include content that clarifies the initiatives or gives you ideas and
tools for implementing their recommendations. For a summary of each of the above
initiatives, see pages 6 and 7.
4 The OR Connection
You Said It!
– Maureen Bollin, RN, CNOR, Perioperative Educator I wanted to pass along a thank you for The OR Connection
magazine you dropped off. I really enjoy reading them. There
As an educator, I was pleased with the timeliness of the is a lot of valuable information in it that I pass along to others.
articles, the activities for the staff and their presentation. The I get a lot of magazines in the mail and I must say this is one
topics are pertinent, and easy to read. I love the variety to of the few I review cover to cover and pass on to others.
articles. I am only sorry I don't have all your issues. This Medline does a nice job with this. Thanks again!
magazine is a great resource tool, and when your staff needs
– Janna Petersen, RN
an in-service, there is always something to draw on. Thank
you for publishing it, I hope it continues.
I love your magazine, keep up the good work!
– K. Smith
– Lynne Arnaut
This type of project is so very valuable to clinicians and
The Back to Basics series has become a hit at our two
establishes your clinical credibility that is a major differentiator in
facilities….I had been working hard on getting staff to read
the market today. Kudos to you and to your clinical team.
your great issues of The OR Connection and now it looks
– Sandy Wise, RN, MBA like it has finally happened.
– Sophia Schild
I received this issue at AORN Congress this year in
Orlando. What a GREAT magazine this is!!! It incorporates
Great issue of The OR Connection! I am just amazed at the
so many of today's issues affecting perioperative care. The
content, information, format, etc. You do have a gift for this
education is invaluable. Thank you!
publication series.
– Rose Trojkovich
– Nancy B. Bjerke, RN, MPH, CIC
I recently got to read Volume 2, Issue 1 given to me by a
fellow OR nurse and I really enjoyed the great reading and Has The OR Connection been helpful at your facility? Is
love the format. I plan on using this info in education of the OR there a topic youʼd love to see us tackle? Drop us a line at
staff in my facility. As an educator I am always looking for orconnection@medline.com. Weʼd love to hear from you!
Hospitals sign up through IHI and can choose to implement some or all of the recommended changes. IHI provides how-to guides
and tools for data measurement and submission. IHI tracks Acute Care Inpatient Mortality rates for all participating hospitals.
The new campaign incorporates the six original planks from the 100,000 Lives Campaign and adds six additional planks to prevent harm.
Joint Commission-accredited organizations are evaluated for compliance with these goals. The Joint Commission
offers guidance to help organizations meet goal requirements.
This yearʼs new requirements have a one-year phase-in period that includes defined expectations for planning,
development and testing (“milestones”) at 3, 6 and 9 months in 2008, with the expectation of full implementation
by January 2009.
SCIP aims to reduce surgical complications in four target areas. Participating hospitals collect data on specific process and
outcome measures. The SCIP committee believes it could prevent 13,000 perioperative deaths and up to 300,000 surgical
complications annually (just in Medicare patients) by getting performance up to benchmark levels.
6 The OR Connection
Patient Safety
To learn more about the proposed 2009 National Patient Safety Goals, go to www.jointcommission.org and see the News Flash on Page
8 of this issue.
8 The OR Connection
News Flash
Medline presents a powerful and comprehensive The six conditions targeted by Prevention Above All
solution to six of the most common hospital-acquired and their complementary Medline product and program
conditions (HACs). solutions are:
• Wrong site surgery
Preventing HACs is one of the most important issues in Surgical Time Out Procedure Drape
health care today. Simply put, the CMS reimbursement • Hospital-acquired infections
changes taking effect October 1 mean healthcare pro- Hand Hygiene Compliance Program
www.medline.com
©2008 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
Special Invitational Forum
Medline presents an executive Prevention Above All forum focusing on
the implications of the new CMS guidelines, targeted interventions and
practical solutions.
Keynote speaker:
John Nance, JD
A founding member of the
National Patient Safety Foun-
dation and one of the foremost
thought leaders on change in
America’s healthcare system
and a regular contributor to
ABC World News and Good
Morning America, John is
also the author of 18 books,
including his latest, Why Hospitals Should Fly: The
Ultimate Flight Plan to Patient Safety and Quality Care.
Featured speakers:
Deborah Adler Diane Krasner, PhD, RN, CWCN, CWS, BCLNC, FAAN
Senior designer at the design firm Milton Glaser, Inc. Board certified wound specialist with extensive experi-
and the inspiration behind Target’s ClearRx system ence in wound, ostomy & incontinence care.
www.medline.com
©2008 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
Special Feature
14 The OR Connection
Generating rave reviews.
www.medline.com
©2008 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
Bovie is a registered trademark of Bovie Medical Corporation.
16 The OR Connection
Eighth in a Series
Patient Safety
Back to Basics
It could happen at any time, to anyone and when you A 68-year-old man was scheduled for ambulatory surgery to
least expect it. If and when it does, your patient, you and your remove a skin lesion on his right cheek. A moderate amount
coworkers could suffer serious injuries, depending upon the of bleeding was encountered during the punch biopsies and
extent and type of error. an electrocautery device was used to cauterize the skin edges
– igniting the nasal cannula and surgical drapes surrounding
The safe and proper use, maintenance and disposal of the face. The surgeon poured sterile water from the operative
electrocautery equipment in the operating room should never tables on the patient and the nasal cannula to extinguish the
be overlooked or taken too lightly. If you do, you could be fire. The nasal cannula and drapes were removed from the
faced with one of the most terrifying experiences of your patient and thrown to the floor. The nasal cannula continued
professional career. Complications and patient injury due to to burn until anesthesia personnel turned the oxygen off. Once
improper use of electrocautery devices include inadvertent the fire was extinguished, new instruments and drapes were
and advertent thermal injury, burn, fire, cardiac arrhythmias obtained. The patient was re-draped and the procedure was
and interference with pacemakers. Although all are serious completed. A thorough examination indicated first- and
complications, a surgical fire can be the most critical.1 second-degree burns involving both cheeks, as well as the
right nasal vestibule.3
Two devastating cases
Following a successful gallbladder surgery at a metropolitan The history of electrocautery
medical center in Boston, a female patient experienced a flash Cauterization began as a means to stop heavy bleeding,
fire ignited on her midsection. The patientʼs abdomen was especially during amputations. The procedure was simple: a
cleansed following her surgical procedure with an alcohol- piece of metal was heated over fire and applied to the wound.
based cleansing solution. The surgeon then decided to This would cause tissues and blood to heat rapidly to extreme
remove a mole from the patientʼs abdominal area using temperatures, causing coagulation of the blood and thus
electrocautery. Blue flames immediately shot up from her controlling the bleeding. Next came medical instruments
midsection – “similar to a flambé,” the surgeon told state called cauters, used to cauterize arteries.
health investigators. The patient suffered painful first- and
second-degree burns.2 Electrocauterization (also called electric surgery or electro-
surgery) is the process of destroying tissue with electricity. It
According to the ECRI Institute, 44 percent of operating room is widely used in many surgical procedures. The procedure is
fires occur during head, face, neck or chest surgery, when most frequently used to stop the bleeding of small vessels or
electrical surgical tools are closest to the oxygen the patient for cutting through soft tissue. The electrocautery generator
is breathing.2 (ESG), more commonly referred to as an electrosurgical unit
18 The OR Connection
According to one ECRI report, an electrosurgical pencil Nitrous oxide use can increase effective oxygen levels above
caused a drape fire because it was not placed in a non- 21 percent. Like oxygen, nitrous oxide also has a vapor
conductive holster.6 In this incident, a pencil fell off the sterile density greater than 1.0. With a vapor density of 1.53, it will
field, was not removed and instead was left dangling. A surgical collect in low-lying areas as well.6
team member leaned against the pencil, causing it to activate,
arc through the drapes to an instrument table and ignite the ECRI data shows that 74 percent of the reported surgical fires
drapes. The flame spread rapidly up the drapes, vertically from occurred when oxygen levels were elevated above 21
the point of ignition, about two feet off the floor, to the patient. percent. It's important to understand that oxygen may collect
By this time, the fire was burning with such intensity that all and its concentration become elevated. This can occur under
other flammable materials on and around the patient ignited surgical drapes, in clothing, on the surface of the skin due to
and quickly burned. This fire was fatal to the patient. Did you the presence of vellus (short, fine, "peach fuzz" body hair) and
know that that materials burn more quickly when vertical? around masks, tubes or nasal cannula when patients are pro-
vided oxygen or nitrous oxide from compressed gas cylinders
There are three conditions that must be in place for a fire to or piped medical gas systems.6
occur: fuel, oxygen and heat. When brought together, these
components complete the fire triangle. Preventing a fire in the To control oxygen concentration levels
OR can be achieved by controlling the elements that make up ECRI recommends6:
the fire triangle. • That the requirement for 100 percent oxygen for
open delivery to the face (for example, when using
Control ignition sources
nasal cannula) be questioned if a lower concentration
The most common ignition sources in the OR are electrosur-
is consistent with the patient needs.
gical and/or electrocautery equipment and lasers. ECRI
reports that approximately 68 percent of surgical fires involve • Stopping supplemental oxygen at least one minute
electrosurgical equipment and 13 percent involve lasers. We before using electrosurgery, electrocautery or laser
have control over ignition sources.6 surgery on the head or neck.
• Titrating the delivery of oxygen to the patient based
ECRI recommends that during electrosurgery6: on the patientʼs blood-oxygen saturation.
• Remove unneeded foot switches to avoid • Tenting drapes to allow gases to drain away from
inadvertent activation. the operating table.
• Place the electrosurgical pencil in its holster when • Using a properly applied incise drape, if possible,
not in active use and place the electrosurgical unit in to help isolate head and neck incisions from
the standby mode. oxygen-rich atmospheres.
• Allow the tip of the pencil to be activated only by the • Considering use of active gas scavenging of space
individual wielding it and when it is under direct beneath the drapes during oxygen delivery. When
observation of the surgeon. scavenging under the drapes, exercise caution so
• Use only active electrode tips that are manufactured that the space beneath the drapes doesnʼt collapse.
with insulating sleeves. • Avoiding the use of nitrous oxide during
• Do not use electrosurgery to enter the trachea. bowel surgery.
• Do not use electrosurgery in close proximity to
combustible materials and oxygen-rich atmospheres. During oropharyngeal surgery, ECRI
• Dispose of electrocautery pencils properly. For also recommends:
example, break off the cauterizing wire and cap • Suction be used as near as possible to any potential
the pencil. breathing gas leaks to scavenge the gases from the
oropharynx of an intubated patient.
Control oxygen levels
We can control oxygen-rich environments in the OR, which in-
clude any atmosphere where there is greater than 21 percent Control combustible materials
oxygen. While oxygen will not burn or explode, it can cause Combustible materials – fuel that will burn – surround the
materials that will not ignite or that burn slowly in ambient air patient in the OR and include the operating table bedding,
to easily ignite and burn rapidly. The vapor density of pure oxygen headrests, clothing, straps, towels, drapes, sponges, dressings,
(1.1) is slightly heavier than air. This means that pure oxygen hair, intestinal gases, tracheal tubes, body tissue, broncho-
may collect in depressions or under drapes or clothing. scopes, breathing systems, petroleum jelly, adhesives, hoses
Continued on Page 21
Ribbed insulation
Rounded blade
ESPB3002
ESRK3002
www.medline.com
©2008 Medline Industries, Inc.
Medline is a registered trademark of Medline Industries, Inc.
and equipment covering – and this list is not complete. The insulation
Flammable and combustible liquids are also present in the failure provides
OR, including skin prep solutions, tinctures, degreasers, an alternate elec-
suture pack solutions and liquid wound dressings. trical current path
between the
Understanding what can burn and which liquids are flammable active electrode
or combustible is the first step in managing the fuel load for a and the patient
potential fire. Allow flammable liquid preps (e.g., preps that are return electrode,
alcohol-based or contain acetone) to fully dry before draping resulting in the
and avoid pooling the liquids when they are applied. Be aware burn. To minimize
that pooled liquids can be wicked up into sponges, drapes, capacitive cou-
etc. and may take longer to dry. ECRI recommends that facial pling, use an
hair (e.g., eyebrows, beards and mustaches) be coated with electrosurgical
a water-soluble surgical lubricating jelly to inhibit combustion.6 waveform with
the lowest volt-
Know and practice the fire plan age necessary
Service-specific fire plans have been required for many years. to achieve the
A fire plan is strongly recommend for surgical service. It should desired surgical
be reviewed annually and it is recommended that quarterly fire effect. Instruments that use active electrode monitoring tech-
5
drills be conducted. Surgical staff members should participate nology (AEM) are also effective in preventing capacitive
in at least one fire drill (conducted in the OR) every year, and coupling.7 These devices are shielded and monitored so that
it is especially important to: 100 percent of their power is delivered where intended.
• Talk about what each OR team member will do if presented
with a fire involving a patient. Refer to the Forms & Tools section starting on Page 76 to find
• Walk through the plan and look for areas where response an Electrocautery Checklist and an Electrosurgical Cautery
can be improved. Safety policy and procedure. For additional support materials
• Know who will be responsible for moving the patient, where regarding fire prevention in perioperative services, refer to
the patient will be moved and who will be moving AORNʼs guidance statement “Fire Prevention in the Oper-
critical equipment. ating Room.”
Not all fires and burns are external to the patient. Internal fires
1 Gamal M, Lamont C, Greene FL, eds. Review of Surgery Basic Science and
Clinical Topics for ABSITE. New York: Springer; 2006.
have been reported in the literature involving patients under- 2 Kowalczyk L. Fires during surgeries a bigger risk than thought. Available at:
going laparoscopic procedures in oxygen-rich atmospheres http://www.boston.com/news/local/articles/2007/11/07/fires_during_surgeries_a
(oxygen was mistakenly used for insufflation instead of _bigger_risk_than_thought/. Accessed July 15, 2008.
3 Joint Commission International Center for Patient Safety. Preventing Surgical
carbon dioxide). They have also been caused by the use of Fires: Who needs to be Educated? Available at: www.jcipatientsafety.org/15196.
lasers and non-metallic endotracheal tubes that were ignited Accessed July 15, 2008.
while in the patient. The burning endotracheal tube created a 4 Cauterization. Available at: en.wikipedia/wiki/Cauterization. Accessed July 12,
fire similar to that which might have occurred had a blowtorch 2008.
5 DeRosier JM, Surgical Fires and Patient Surgical Burns. NCPS Tips – August/
scorched the lungs. September 2003. Available at: www.va.gov/NCPS/TIPS/Docs/TIPS_Aug_Sept_
03.doc. Accessed July 14, 2008.
Stray electrosurgical burns can cause internal injuries that 6 Focus on surgical fire safety. ECRI Health Devices. 2003;32(1):4-40.
3 4
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8 9
10
11 12
13 14
15
16
17 18
19 20
21 22 23
24
25 26
27 28
29
30
22 The OR Connection
Across Down
1 Electrical fires due to the improper use of electro- 2 Do not use electrosurgery to enter the _____.
cautery equipment are a potentially devastating 3 Do not use electrosurgery in close proximity to
yet _____ adverse event. _____ materials and oxygen-rich atmospheres.
4 Complications and patient injury due to improper 12 Electrocauterization is the process of destroying
use of electrocautery devices include inadvertent tissue with _____.
and advertent thermal injury, burn, _____, cardiac 14 Different _____ effects can be achieved by
arrhythmias and interference with pacemakers. changing the voltage of the current as well as the
5 A common monopolar _____ is pen-shaped. pattern of electric pulses.
6 Use only active electrode tips that are manufactured 16 Allow the tip of the pencil to be _____ only by the
with _____ sleeves. individual wielding it and when it is under direct
7 Electrocautery is most frequently used to stop the observation of the surgeon.
bleeding of small vessels or for_____ through soft 18 Electrosurgery can be performed safely at “radio”
tissue. frequencies _____ 100 kHz.
8 Cauterization began as a means to stop heavy 19 With _____ cauterization, current is passed from
_____, especially during amputations. the active electrode, where cauterization occurs,
9 To prevent electric shock, an alternating frequency and the patientʼs body serves as a ground.
that is _____ than power from standard wall outlets 20 _____ of electrocautery pencils properly. For
is used. example, break off the cauterizing wire and cap
10 The placement of the return _____ is critical in the pencil.
preventing extensive burns. 22 It's important to understand that oxygen may
11 _____ fires have been reported involving patients collect under drapes and in clothing and its
undergoing laparoscopic procedures in oxygen-rich concentration become _____.
atmospheres. 23 _____ reports that approximately 68 percent of
13 Preventing a fire in the OR can be achieved by surgical fires involve electrosurgical equipment.
controlling the elements that make up the 25 A grounding pad is placed on the patientʼs body,
fire _____. usually on the _____, and serves as the returning
15 There are three conditions that must be in place for electrode, carrying the current back to the machine.
a fire to occur: _____, oxygen and heat. 26 A _____ setting is available with most electrocautery
17 In bipolar cauterization, the active and receiving devices which allows for cutting and coagulation.
electrodes are both placed at the site of _____.
21 Remove unneeded foot switches to avoid
_____ activation.
24 The typical bipolar probe resembles a pair
of _____.
27 Place the electrosurgical pencil in its _____ when
not in active use and place the electrosurgical unit
in the standby mode.
28 A fire _____ is strongly recommended for
surgical service.
29 When a higher _____ current is used in a pulsed
manner, tissue damage is more widespread and
blood coagulates.
30 _____ what can burn and which liquids are
flammable or combustible is the first step in
managing the fuel load for a potential fire.
24 The OR Connection
Patient Safety
Left Behind
Retained foreign bodies harm
both patients and finances
By Megan Giovinco, RN, CNOR, RNFA
A 42-year-old woman presented with a five-month history adhesions and death.2 If this was not enough to make surgical
of abdominal pain, nausea and vomiting. Physical exami- facilities reexamine their count policies, the fact that they will
nation revealed a palpable epigastric mass. Five months not receive their full Medicaid and Medicare reimbursements
prior, the patient had undergone an abdominal hysterectomy if they fail to take steps to prevent eight avoidable hospital-
for uterine leiomyomata. The rest of her examination and acquired conditions – including RFOs – will. In short, if a
history were unremarkable. An abdominal computed tomog- patient must return to surgery to remove a foreign object left
raphy (CT) scan was performed. Review of this and the Scout behind during a previous procedure, the hospital will have to
image from the CT revealed a “density consistent with a foot the bill.5
laparotomy sponge in the left lower quadrant of the
abdomen.” The patient returned to surgery for an exploratory Traditionally, the manual counting of sponges, sharps and
laparotomy and a sponge from her first surgery was found instruments has been a utilized standard of practice in the sur-
and removed.1 gical setting. Although helpful, there is no published data dis-
cussing the effectiveness of this practice.4 In fact, according
How serious is the problem? to a study done by the New England Journal of Medicine, in
Gossypiboma, or retained foreign objects, are a dangerous almost 90 percent of cases involving a retained foreign ob-
and costly issue.2 Current studies have found that retention of ject, a count was performed per policy and all objects were
sponges, sharps or instruments can occur as frequently as reportedly accounted for.6 Certain assistive devices such as
one in every 100 cases or 1 in every 5000 cases. According hanging bags to place sponges in, needle boxes on the sur-
to the American College of Surgeons, any facility that gical field and wall-mounted boards for count documentation
performs 8,000 to 18000 major cases annually will have one have helped, but items continue to be left behind.4
incidence of a retained item yearly.3 These statistics are
based on claims data, but it is highly probable that even more How does this happen?
cases are settled outside the legal system every year. In So why do items get left behind? The surgical team is made
addition, it is likely that many more circumstances where up of dedicated and conscientious healthcare providers –
“near misses” – incorrect counts of sponges and instruments including anesthesiologists, surgeons, nurses and surgical
that were identified and resolved intraoperatively via manual technicians – who are committed to a common goal of safe,
searches and X-rays – have happened.4 The average settle- efficient and effective functionality. These professionals
ment in malpractice cases involving RFOs is $50,000. These constantly execute challenging tasks under considerable time
items that are inadvertently left behind when the surgical pressures, often in chaotic, constantly changing, stressful
incision is closed can cause pain, sepsis, bowel perforation, situations.4 Although these practitioners have been trained
and have the experience to deal with such an environment, them up to date with AORN Standards and Recommended
human error can occur – especially when so many distractions Practices.9 These routine assessments of policy should also
are present.7 Other risk factors that contribute to a greater include investigating any new tools or procedures available
chance of something being missed include emergency surgery, that will increase patient safety and reduce retention
unplanned changes in the procedure, patients with a high of counted items.6 Many institutions encourage obtaining a
body mass index, multiple changes in the surgical team and routine X-ray of any case considered high risk for a RFO,
multiple operative sites.2 such as traumas or morbidly obese patients.3 However, it has
been noted in a recent study that three out of 29 X-rays
Well, what more can be done? As with many things, commu- obtained for an incorrect count falsely reported that no
nication is key. Good communication between the surgical foreign objects were seen on the films.9
team is necessary for the prevention of retained foreign
objects.8 Intraoperatively, distractions, interruptions, noise Technological advances
and traffic should be as limited as possible. When staff New technologies, such as radio frequency identification,
changes occur, complete and accurate transmission of have recently been gaining acceptance in many of the
relevant information must be shared. This information nationʼs ORs. Radio frequency ID-tagged sponges are elec-
should also be documented according to facility policy. To- tronically tagged with a small microchip about 4 x 12 mm in
ward the end of the procedure, the final count of surgical size. This chip is small and sturdy enough that the sponges
sponges, sharps and instruments should be performed and that house it can be used the same way non-RFID sponges
include a visual and audible confirmation by at least two are. Detection is still possible even if the gauze is balled or
team members. This information should then be relayed to folded up. One can even clamp directly over this chip without
the surgeon prior to closure of the surgical site.4 impairing its functionality.10 By passing a hand-held, battery-
powered wand over the patient, one can detect whether or
not a sponge was left behind.9 These RFID chips are available
in sponges, gauze and towels in a variety of sizes. The wand
Although following these guidelines
can also be used off the surgical field by the circulator to scan
will augment accuracy and reduce
errors, the fast pace and ever- for sponges that may have been inadvertently thrown into
changing conditions of the OR the trash.10
Continued on Page 28
26 The OR Connection
Searching for that
one last sponge?
©2008 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
www.medline.com
RF Detect® is a registered trademark of RF Surgical Systems, Inc.
RF Surgical® is a registered trademark of RF Surgical Systems, Inc.
Performing surgical counts accurately and efficiently is one
of the first things taught to perioperative professionals.9
Everyone involved in the surgical procedure shares an ethical,
moral and legal responsibility to provide the patient with the
safest possible care. This includes assuring that no foreign
objects are retained where they can cause pain, harm,
further surgery or even death. To do this calls for the following
guidelines set up by the American College of Surgeons to be
followed:2
• Effective communication among perioperative staff
• Consistent application and adherence to individual facility
standards for counting procedures
• Performance of a methodical wound exploration prior to
closure of the surgical site
• Use of X-ray detectable items in the surgical site
• Maintenance of the most optimal OR environment possible
to allow for focused performance of tasks
• Use of X-ray and RF technology as indicated to ensure
there are no items remaining in the surgical field
a retained item.3 after surgery. Bulletin of the American College of Surgeons. 2005;90(10).
5 Brandon G. Rule denying payments for “never events” will force a close look at
current practice. AORN Management Connections. October 2007:3(10).
6 The Joint Commission International Center for Patient Safety. Reducing the risk of
unintentionally retained foreign bodies. Available at:
http://www.jcipatientsafety.org/15199/. Accessed July 18, 2008.
7 RF Surgical Systems Inc. Retained surgical objects: costly to avoid and over-
come… until now. Available at: www.rfsurg.com/retainedobjects.htm. Accessed July
18, 2008.
8 American College of Surgeons. [ST-51] Statement on the Prevention of Retained
Foreign Bodies after Surgery. Available at: http://www.facs.org/fellows_info/state-
ments/st-51.html. Accessed July 18, 2008.
9 Murdock DB. Trauma: when thereʼs no time to count. AORN Journal. February
About the author 2008:87(2):322-28.
Megan Giovinco, RN, CNOR, RNFA, currently a clinical nurse 10 RF Surgical Systems Inc. Features. Available at: http://www.rfsurg.com/fea-
tures.htm. Accessed July 18, 2008.
consultant, has been an RN for more than 10 years. Previously,
she worked as a nurse at a number of acute care facilities and
trauma centers.
28 The OR Connection
Everything you need to
know about your packs
at your fingertips.
www.medline.com
©2008 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
Patient Safety
To improve surgical safety worldwide, likelihood that patients will receive a higher
the World Health Organization (WHO) has standard of surgical care, with adherence
released a new safety checklist for surgical to these standards improving from 36% to
teams to use in operating rooms, accord- 68%, and to nearly 100% in some hospitals.
ing to a report regarding the Safe Surgery Better adherence has been linked to
Saves Lives initiative, published online significant reductions in surgical morbidity
June 25 in The Lancet and also available and mortality, although final results are not
on the WHO Web site. These WHO guide- yet available.
lines and checklist are the first edition, and
they will be finalized for dissemination by late The checklist covers 3 phases of a surgical
2008, after completion of evaluation in 8 pilot procedure: before anesthesia is induced,
sites globally. before skin incision, and before the patient
leaves the operating room. For each phase,
"Preventable surgical injuries and deaths are now a growing a checklist coordinator confirms that the team has com-
concern," Margaret Chan, MD, director-general of WHO, says pleted the designated tasks before the next phase of the
in a news release. "Using the Checklist is the best way to operation occurs.
reduce surgical errors and improve patient safety."
Before induction of anesthesia, key components of the
High mortality and morbidity of major surgical procedures mandate checklist, using the mnemonic "Sign In," are as follows:
global public health and surveillance measures to improve
surgical safety, especially in low-income areas with limited • Check that the patient has confirmed their identity, the
surgical access. Estimates suggest that about half of surgical surgical site, and the procedure to be done and that the
complications may be preventable. patient has given informed consent.
• The surgical site should be marked, if applicable.
The Safe Surgery Saves Lives initiative, a collaboration of more • The anesthesia safety check should be completed.
than 200 national and international medical societies and • The pulse oximeter should be placed on the patient
ministries of health led by the Harvard School of Public Health,
and functioning.
aims to reduce avoidable surgical mortality and morbidity. The
• Check to see if the patient has (1) A known allergy. If so, these
newly developed WHO Surgical Safety Checklist provides a set
should be documented. (2) An anatomically difficult airway to
of surgical safety standards applicable to all countries and
intubate or aspiration risk. If so, additional equipment and
health settings.
assistance should be available. (3) Risk of more than 500-mL
blood loss in adults or 7 mL/kg in children. If so, provision
At 8 pilot sites worldwide, preliminary findings from 1000
should be made for adequate intravenous access and fluids.
patients suggest that using the checklist has nearly doubled the
30 The OR Connection
Before skin incision, the checklist uses the mnemonic Before the patient leaves the operating room, the
"Time Out" for the following components: checklist uses the mnemonic "Sign Out" for the
following components:
• Confirm that all team members have introduced themselves
both by name and by their role on the surgical team. • The nurse verbally confirms with the team the name of the
procedure to be recorded and verifies instrument, sponge,
• The surgeon, anesthesia professional, and nurse should and needle counts, if applicable; labeling for the surgical
verbally confirm the patient's identity, surgical site, and specimen, including patient name; and whether there are
procedure to be performed. any equipment problems to be addressed.
• Anticipated critical events to be reviewed by the surgeon • The surgeon, anesthesia professional, and nurse review
the key concerns regarding recovery and management of
are any critical or unexpected steps, estimated operative
the specific patient.
duration, and anticipated blood loss.
• Anticipated critical events to be reviewed by the nursing team "Surgical care has been an essential component of health
are confirmation of sterility of the tools, supplies, and field systems worldwide for more than a century," says checklist
(including indicator results); documentation and discussion coauthor Atul Gawande, MD, MPH, a surgeon and professor
of any equipment issues or concerns; whether antibiotic at Harvard Medical School in Boston, Massachusetts.
prophylaxis has been given within the last 60 minutes, if "Although there have been major improvements over the last
applicable; and whether essential imaging is displayed, few decades, the quality and safety of surgical care has been
if applicable. dismayingly variable in every part of the world. The Safe
Surgery Saves Lives initiative aims to change this by raising
the standards that patients anywhere can expect."
Lancet. Published online June 25, 2008. Reprinted with permission.
By Stephen W. Harden
32 The OR Connection
Special Feature
Defining culture
There are numerous definitions of culture. Everyone seems
to have their own take on it. After working with over 80 healthcare
organizations in the past eight years to help them create and
sustain a culture of safety based on the best practices of
high-reliability organizations, I have come to believe the
definition of culture is this: “The cumulative effect on the
organization of the actions of the people within the organization
at daily moments of truth.”
Continued on Page 36
34 The OR Connection
Break down the barriers
to hand hygiene
compliance.
We know that cracked, dry, irritated hands are a barrier to Sterillium Comfort Gel is just one of the premier
hand hygiene compliance — but we also know that hand products in Medline’s Healthy Hands Bundle. To
hygiene is the number one line of defense against hospital- learn more about these products and our Hand
acquired infections.1,2 Hygiene Compliance Program, contact your
sales rep, call 1-800-MEDLINE or visit
How do you get the results you demand without sacrificing www.medline.com/handhygiene.
your skin? By choosing Sterillium® Comfort Gel™, which is
proven to increase skin hydration by 14 percent in just two
weeks — while still delivering greater efficacy than other al-
cohol-based hand antiseptics.*
* Data on file
References
1 Pittet D. Improving compliance with hand hygiene in hospitals. Infect Control Hosp Epidemiol. 2000;21:381-386.
www.medline.com
2 Davis D, Sosovec D. The value of products that improve hand hygiene and skin. Healthcare Purchasing News. Available at:
http://www.hpnonline.com/inside/2003-11/1103hygiene.htm. Accessed November 20, 2007.
actions needed in a learning environment so they will skillfully
be used at the moment of truth.
36 The OR Connection
Surgical Site
Infections
Are you playing your part
in prevention?
antibiotics, usually intravenously, should be timed so that a bac- rate: a new need for vital statistics. Am J Epidemiol. 1985;121:159-67.
4 Commission on Accreditation of Allied Health Education Programs. Surgical Technologist. Avail-
tericidal concentration is present in blood and tissues by the time able at: http://www.caahep.org/Content.aspx?ID=53. Accessed July 1, 2008.
the surgical incision is made and maintained until closure of the 5 Fuller JK. Surgical Technology: Principles and Practice. 4th ed. St. Louis, Mo.: Elsevier Saunders;
now a standard of care and recommended practice in most 7 Tanner J, Woodings D, Moncaster K. Preoperative hair removal to reduce surgical site infection.
Cochrane Database Syst Rev. 2006 Apr 19;(2):CD004122.
healthcare facilities. 8 Kurz A, Sessler DI, Lenhardt R. Perioperative normothermia to reduce the incidence of surgical-
wound infection and shorten hospitalization. Study of Wound Infection and Temperature Group.
38 The OR Connection
Slay bacteria
with silver.
Fight wound bioburden and bacteria with Arglaes®. The Arglaes® gives you options
Arglaes family of products harnesses the power of con- Arglaes® Film is ideal for managing bioburden on post-
trolled-release, non-cytotoxic antimicrobial silver in a op and line sites, Arglaes® Island features a calcium
variety of forms for even your most stubborn wounds. alginate ad for fluid management in addition to con-
trolled-release silver and Arglaes® Powder is the perfect
®
Arglaes : solution for your difficult-to-dress wounds and can be
• Reduces bioburden easily combined with other dressings to create a system
• Provides constant antimicrobial protection for bioburden control.
• Effective against bacteria and fungi without harming
healthy tissue To learn more about Arglaes® and which products
best fit your specific needs, contact your sales
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Arglaes® Film
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©2008 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
Great Ideas from Your Peers
At St. Vincentʼs Medical Center in Indianapolis, Indiana, solution, particularly as it relates to reducing facility-
Paul Durgan, staff educator for surgery, came up with acquired infections following surgical procedures.
an innovative way to assist surgical personnel in
providing the most effective prep solution in an This led to the idea of creating a custom surgical prep tray
efficient and cost-effective manner. Paulʼs goals were that only contained supplies that could be used in almost
to offer a high-efficacy surgical prep solution while simul- every procedure. Of course, Paul wanted to be sure that
taneously reducing the waste associated with the facilityʼs chlorhexidine was the preferred prep solution, so they
current prep kit. He had observed staff members choose a four-ounce bottle containing 4 percent CHG.
discarding most of the contents in their current prep Additional components in the tray include 100 ml saline
tray and adding their preferred solution. (for diluting or rinsing), three sponge sticks, six winged
sponges, two cotton swab applicators, two blue cloth towels
The CDC strongly recommends using 2 percent chlorhex- and two white cloth towels. They chose cloth towels for
idine (CHG) solution for skin antisepsis. Two percent better absorbency and also because they have much less
chlorhexidine solution has been shown to be six times memory than a paper towel, which can spring back after
more effective than alcohol and povidone-iodine in placement and lead to cross contamination.
cleaning the skin and in inhibiting microbial growth for
days afterward.1 In two studies measuring persistent
Creating a custom surgical prep
efficacy, chlorhexidine demonstrated significant residual
tray enabled St. Vincent’s to realize
antimicrobial effects for five days and was more effective
a 29 percent cost savings over their
than isopropyl alcohol, alcohol or povidone-iodine alone.1
previous trays. They lowered their
per-tray cost by $2.78.
Paul had the opportunity to attend a seminar in which Dr. Because CHG cannot be used to prep eye, ear or genital
Allan Morrison Jr., an epidemiologist and chairperson of procedures, the need for additional prep solutions is appar-
Infection Control at Inova Fairfax Hospital and clinical ent. Paul is actively searching for a CHG prep that can be
assistant professor at Georgetown University Hospital, used on genital areas and will let us know when he finds
discussed the benefits of chlorhexidine as a surgical prep his next solution.
40 The OR Connection
OR Issues
St. Vincentʼs orthopedic department has also recently Improved efficiency, decreased waste, better patient care
initiated a study with their total joint patients, asking them and cost savings are all the results of one innovative
to shower with CHG the night before their surgery. The change. Whereas there is often a perception that
CDC also recommends that surgical facilities require customization leads to increased cost, when you find that
patients to shower or bathe with an antiseptic agent at standardized solutions result in throwing away supplies
least the night before surgery.2 Additional information will that are not wanted or used, one can easily see where
be shared as the results of this study become available. customization can provide a cost effective solution.
Paul Durgan has been the staff educator for surgery at St.
Vincentʼs Medical Center in Indianapolis, Indiana, since 2005.
Paul says that this position has helped him “attain a broader
Components of the Custom Surgical Prep Tray perspective of current needs for patient care as well as physician
and associate satisfaction.” He credits the development of the
• Four-ounce bottle of 4 percent CHG CHG prep kit as an area in which he was able to promote a cost-
• 100 ml saline (for diluting or rinsing) effective solution to one of his facilityʼs needs.
• Three sponge sticks
• Six winged sponges
References
1 Hibbard J et al. A clinical study comparing the skin antisepsis and safety of
• Two cotton swab applicators ChloraPrep, 70% isopropyl alcohol, and 2% aqueous chlorhexidine. Journal of
Infusion Nursing. 2002;25(4):244-49.
• Two blue cloth towels 2 Nichols RL. Preventing surgical site infections: A surgeon's perspective.
• Two white cloth towels. Emerging Infectious Diseases. 2001;7(2).
www.medline.com
©2008 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
Patient Safety
After a leisurely lunch in the outdoor café, Sandy and Joe dimmed and then the case was underway. This will be a quick
checked their afternoon assignment. They were to relieve case, Sandy thought to herself as she opened the vial of sterile
the staff in OR 31. Sandy and Joe entered the OR through the talc to the field. She finished her computerized charting and,
sterile core as the surgeon was initiating the time-out. Joe within what seemed like minutes, Joe was ready to do the first
opened his gown and gloves while Sandy received report from closing count. After they completed their counts, Sandy opened
the circulating nurse. The patient was a young anorexic woman the chest drainage tubing to the sterile field and filled the chest
with no known allergies who was undergoing a right thora- drain with water. The second counts were completed soon after
coscopy and chemical pleurodesis for recurrent pneumothorax. and Sandy called for moving and lifting help as Joe placed the
She was positioned in a lateral position right side up on a dressings over the small incision sites.
bean-bag positioner. A towel roll was placed under her axilla.
Her arms were padded with foam and pillows and secured on Joe removed the drapes from the patient as the surgical assis-
arm boards with two pillows placed between her legs. She was tants brought the stretcher into the room and stood at the side
secured to the OR bed by a safety strap across her thighs as of the operating room table in preparation for repositioning of
well as tape across her hips. the patient for extubation.
After he was gowned and gloved, Joe handed Sandy the light Joe asked Sandy to step around to his side of the OR bed. He
and camera cords. The surgeon asked for the room lights to be pointed to an area where a portion of the draw sheet covering
44 The OR Connection
Intraoperatively Acquired Pressure Ulcers4,5,6
• Initially appear as a burn like lesion. About the author
Jayne Barkman, RN, BSN, CNOR, has 29 years of perioperative
• Occur most frequently in patients undergoing general,
experience in various roles, including surgical technologist, staff nurse
thoracic, orthopedic, cardiac and vascular procedures. and clinical educator. She currently works as a clinical nurse consultant.
• Have been documented to occur in 12 percent to 66
percent of surgical patients.
• Account for 42 percent of nosocomial-acquired References
pressure ulcers. 1 AORN. Recommended practices for positioning the patient in the
• Add an additional cost of up to $60,000 per patient or perioperative practice setting. In: Standards, Recommended Practices,
and Guidelines. Denver, Colo.: AORN, Inc; 2006:587-590.
750 million to 1.5 billion dollars annually.
2 Hoshowsky VM, Schramm CA. Intraoperative pressure sore prevention:
An analysis of bedding materials. Research in Nursing & Health.
1994;17(5):333-39.
3 Edlich RF, Winters KL, Woodard CR, Buschbacher RM, Long WB,
Typically, perioperative nurses have no contact with the patient
Gebhart GH, Ma EK. Pressure ulcer prevention. J Long Term Eff Med
postoperatively and therefore the ramifications of intraopera-
Implants. 2004;14(4):285-304.
tively caused pressure ulcers are unknown to the perioperative
4 Pressure Ulcers Risk Analysis (Healthcare Risk Control November
staff. The Association of periOperative Registered Nurses
2006). Available at: www.ecri.org/documents/patient_ safety_center/
(AORN) recommends doing a thorough preoperative interview
pressureulcers.pdf. Accessed July 23, 2008.
and assessment to determine the appropriate positioning
5 Ankrom MA, Bennett RG, Springle S et al. Pressure-related deep tissue
devices required for each individual patient. Their guidelines
injury under intact skin and the current pressure ulcer staging systems.
state that the perioperative nurse should be involved in
Advances in Skin & Wound Care. 2005;18(1).
positioning the patient as well as monitoring for proper body
6 Wilhelmi BJ. Pressure Ulcers, Surgical Treatment and Principles. Avail-
alignment and the tissue integrity of the patient after position-
able at: http://www.emedicine.com/plastic/topic462.htm. Accessed July
ing and during the surgical procedure. A skin assessment
23, 2008.
should be repeated when the procedure is finished with docu-
mentation of the assessment. The recommended practices also
state that positioning policy and procedures should be acces-
sible to the staff and be reviewed and revised annually.1
46 The OR Connection
By Claudia Sanders, RN, CFA
5
GIMME There are many contributing factors for pressure
ulcers, including:
• Circulation
• Mechanical stress
• Temperature
• Too wet/ too dry (moisture)
• Infection
• Chemical stress
• Medications
• Disease
• Nutrition
• Age
• Body build
A number of these factors are out of our control, but others can
be affected positively with the appropriate tools and practices.
Following is a list of five of these factors and some considerations
Five pressure ulcer you will want to examine the next time you are caring for
patients at risk for pressure ulcers.
factors to keep in mind
1. Age
It should come as no surprise that the older we are, the more
fragile our skin becomes. Skin becomes thinner, drier and has
a tendency to break down easily. The elderly are also at a
higher risk for poor circulation. Clearly, these patients need to
be handled with gentle and caring hands.
Keep in mind how long you may have this patient lying on a
stretcher in a holding area. Ask the patient to move themselves
if possible or encourage and help move the patient if they are
lying in one position for long periods of time. And pad those
areas where pressure ulcers most commonly occur when
patients are lying down: back of the heels, knees, buttocks,
tailbone and hipbone. Same goes for when you have
brought the patient into the operating room and placed
him on the operating room bed. Proper positioning of the
patient and padding of bony prominences is vital in preventing
pressure ulcers while patients are in surgery. Your facility may
want to invest in gel table pads for stretchers and operating
room beds as well as gel positioners.
48 The OR Connection
Join the program
to reduce pressure ulcers.
Medline’s Pressure Ulcer Prevention Program The Pressure Ulcer Prevention Program from Medline will help
you in your efforts to reduce pressure ulcers in your facility.
Systematic efforts at education, heightened awareness and
specific interventions by interdisciplinary healthcare teams
The program includes:
have demonstrated that a high incidence of pressure ulcers
• Education for professional staff and nurse technicians
can be reduced.1
• Teaching materials for you to help train your staff
• Practical tools to help reduce the incidence of pressure ulcers
The main challenges to having an effective pressure ulcer
• Innovative products supported by evidence-based information
prevention program are lack of resources, lack of staff education,
that results in better patient care
behavioral challenges and lack of patient and family education.2
References
www.medline.com
1 Holmes A, Edelstein T. Envisioning a world without pressure ulcers. ECPN. 2007;122(8):24-29.
2 CMS Roundtable, Omni Hotel, Chicago, Ill. March 10, 2008.
©2008 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
The History of the
SURGICAL
TECHNOLOGIST
50 The OR Connection
OR Issues
The workplace is full of a wide variety of job titles and technicians. According to this plan, schools were to be
initials to place behind your name. They often sound established at the Army Medical Center and four other
significant, but did you ever wonder where they came general hospitals for the formal education of surgical tech-
from? What caused a need for the professions (and pro- nologists. Prior to this, technicians were simply trained on
fessionals) of today? At some time, every vocation was the job.2
new, including that of the surgical technologist. So what
spurred the need for them? It was not until 1940 that Dr. Parranʼs plans began to be
executed. In 1941, the first school of surgical technology
The advances in medical technology, from antibiotics to was in session. By July of 1942, 410 students were
blood transfusions, have often come during times of war. enrolled. With the entrance of the United States into World
This same setting fostered the need for surgical technol- War II, there was an even greater need for surgical
ogists. Initially, the role of the nurse basically entailed personnel. More schools were quickly established and the
assisting the surgeon during procedures. However, as number of “scrubs” more than doubled in order to meet
various wars depleted nursing resources, other ways of the demand of the military hospitals both at home and
providing patient care during surgery had to be explored.1 abroad.2
In 1939, Dr. Thomas Parran Jr. (then the U.S. Surgeon The nursing shortage worsened as the war continued and
General) proposed the Protective Mobilization Plan, which more and more wounded soldiers were in need of care.
pushed for the training of enlisted medical and surgical Nurses were in great demand to staff not only local facil-
and establishing the sterile field • Operate lights and suction machines
• Set up surgical instruments and equipment • Assist with diagnostic equipment
• Gloving
• Pass instruments and sterile supplies to the surgeon
• Ensure the integrity of the sterile field throughout the procedure • Manage central supply departments
Outside of the OR, they
male technologists, the department began accepting 2 Office of Medical History, Office of the Surgeon General. Medical Department, United
States Army Medical Training in World War II. Available at:
women into its programs in 1943. The Surgeon General http://history.amedd.army.mil/booksdocs/wwii/medtrain/frameindex.html. Accessed June 17,
surgical technology had to be expanded yet again.3 4 Association of periOperative Registered Nurses. AORN History. Available at:
http://www.aorn.org/AboutAORN/AORNHistory/. Accessed June 17, 2008.
5 Association of Surgical Technologists. About AST. Available at: http://www.ast.org/abou-
The nursing shortages caused by World War II and the tus/about_ast.aspx. Accessed June 17, 2008.
52 The OR Connection
Medline’s Hand Hygiene
Compliance Program
References
1 Centers for Medicare & Medicaid Services. Medicare program; changes to the hospital inpatient prospective payment systems and
fiscal year 2007 rates. Available at: www.cms.hhs.gov/AcuteInpatientPPS/downloads/CMS-1533-FC.pdf. Accessed November 20,
2007.
2 Davis D, Sosovec D. The value of products that improve hand hygiene and skin. Healthcare Purchasing News. Available at:
http://www.hpnonline.com/inside/2003-11/1103hygiene.htm. Accessed November 20, 2007.
www.medline.com
©2008 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
Special Feature
A Place of Healing?
Violence is increasingly
common in health care
By Laura Kuhn
The OR Connection staff writer
Itʼs ironic when you stop and think about it – hospitals are
places where patients go to get better, yet for some
healthcare employees theyʼre also places fraught with
intimidation, harassment and even violence.
54 The OR Connection
Obviously, healthcare workers can’t control
which patients come through the doors of their
facilities. They can, however, have a strategy
in place for preventing violence and effectively
halting it when it does happen.
Defining violence in the workplace waiting rooms, among others.1 Violence is also more likely to
The CSPS defines workplace violence and its elements in its erupt when facilities are understaffed, especially during meal
Statement on Violence in the Workplace1: times and visiting hours.1
Workplace violence includes, but is not limited to, intimidation, Healthcare workers are also more likely to encounter violence
threats, physical attack, property damage and sexual harassment. when they work alone or directly with volatile people, espe-
cially if those people are under the influence of drugs or
Intimidation includes, but is not limited to, stalking or alcohol, have a history of violent behavior or have been
engaging in actions intended to frighten and coerce. diagnosed with certain psychiatric conditions.1
Property damage is intentional damage to property. The U.S. Occupational Safety and Health Administration
(OSHA) lists the following as the five key components in the
Sexual harassment is unwelcome advances, requests for prevention of workplace violence2:
sexual favors, and other verbal or physical conduct of a sexual
nature, when submission to or rejection of this conduct Management commitment and employee involvement
explicitly or implicitly affects a person's employment or Management and frontline employees must work together as
education, unreasonably interferes with a person's work or a team or committee for a violence-prevention program to be
educational performance or creates an intimidating, hostile successful. Management must show concern for employee
or offensive working or learning environment. safety and allocate appropriate resources. Employees must
comply with the workplace violence prevention program and
Triggers for violence in the healthcare workplace report violent incidents promptly and accurately.
Many patients who are treated in hospitals and other care
facilities are at an increased risk of exhibiting violent behavior. Worksite analysis
Medical conditions associated with violent tendencies include A worksite analysis is a commonsense look at the workplace
hypoglycemia, electrolyte imbalance, anemia, hypoxia, alcohol to find existing or potential hazards for workplace violence. A
intoxication, pain, dementia and the use of codeine, PCP, threat assessment team, patient assault team or similar task
LSD and other drugs.3 However, while these factors might force or coordinator can assess the vulnerability of the work-
make a person more likely to behave in a violent manner, the place and determine the appropriate actions to be taken.
individualʼs tendency toward violence must still be triggered in
some way.4 These triggers are referred to as “situational factors.”4 Hazard prevention and control
After hazards are identified through the worksite analysis,
There are a number of situational factors present in hospitals design measures should be taken (whether through engi-
that can contribute to violent behavior. These include poor neering or administrative and work practices) to prevent and
environmental design, inadequate security, access to control these hazards.
firearms, poorly lit areas and overcrowded, uncomfortable
References
1 Council on Surgical & Perioperative Safety. Statement on Violence in the Work- 4 Cooper C, Swanson N. Workplace violence in the health sector: state of the art.
place. Available at: http://www.cspsteam.org/education/education8.html/. Ac- Geneva, Switzerland: International Labour Office, 2002. Available at:
cessed June 19, 2008. http://icn.ch/state.pdf. Accessed June 19, 2008.
2 U.S. Department of Labor. Guidelines for Preventing Workplace Violence for 5 Massachusetts Nursing Association. Ten Actions A Nurse Should Take If
Health Care & Social Service Workers. Available at: http://www.osha.gov/Publica- Assaulted at Work. Available at:
tions/OSHA3148/osha3148.html. Accessed June 19, 2008. http://www.massnurses.org/health/articles/top_ten3.htm.
3 Carroll V. Preventing violence in the healthcare workplace. Alabama Nurse. Accessed June 19, 2008.
2004 Mar-May.
56 The OR Connection
When one thinks of the operating room, phrases like
“cutting-edge technology,” “the future of medicine” and
“the newest procedures” come to mind. Although this is true,
comments like “This is how we have always done it” and “What?
Something new to learn?” are often heard as well. While these
barriers are hard to overcome, the OR of the future has many
champions, including Callie Craig, Team Manager and Periop-
erative Clinical Educator at INTEGRIS Baptist Medical
Center in Oklahoma City, Oklahoma.
58 The OR Connection
Special Feature
References
1 The Joint Commission. The Statistics page. Available at: http://www.jointcommission.org/NR/rdonlyres/D7836542-A372-4F93-8BD7-
www.medline.com
©2008 Medline Industries, Inc. Medline is a registered trademark of Medline Industries, Inc.
Caring for Yourself
By Brian Tracy
62 The OR Connection
Special Feature
and financial officer would fit into this category. Next are the
project managers. They are responsible for making sure
that the talent and resources are organized in such a way
that the project gets done. Next is the talent. These are the
people who have the skills to get the job done, such as
nurses, OR techs and other front-line healthcare profes-
sionals. To thrive in this tough economy, it is important that
you master “winning management” skills so that you can
perform equally well in the project manager or resource
provider role. (For details read my Winning Management:
6 Fail-Safe Strategies for Building High-Performance
Organizations book.)
Think global
Globalization is accelerating at a nanosecond pace. To take
advantage of globalization, you must dramatically increase
your cultural awareness. If you are now employed in a
primarily “homogeneous” organization and are not at least
90 percent satisfied, seek employment in a multicultural
organization. Donʼt know where to start? Get a copy of
Time to put yourself in the driverʼs seat of your career by Fortuneʼs latest issue of either 100 Best Companies to Work
developing new skills that will enable you to take advantage For (typically published in February) or Americaʼs Most
of the opportunities that are unfolding before your very Admired Companies (typically issued in March of every
eyes – opportunities that will enable you to not only survive, year) and apply to any of the companies listed. Want to stay
but thrive in this tough economy. in health care? Not a problem, there are many on either list.
For example, Methodist Hospital System is in the number
Think projects 10 spot on the 2008 100 Best Companies to Work For and
Old organizations were organized by departments and Manor Care is in the number one spot for the Healthcare
position titles. Today, projects accomplish most work. To Medical Facilities Group in the 2008 Americaʼs Most
thrive in a project environment, recognize that work gets Admired Companies.
done primarily by three distinct specialties. First, there are
the resource providers. These are the folks who develop Equally important, learn a foreign language. If youʼre not
and supply talent or money. Your human resource manager fluent in at least one foreign language, you will be in trouble
Focus on delivering exceptional quality service The other side of the coin is to keep asking “How have I
Delivering exceptional quality service is not an option, but ʻgrownʼ in my job today?” To make this happen, think of
rather a survival strategy. We must be absolutely clear going to work each day with a “briefcase” of skills and com-
about who provides us with our paycheck. No, itʼs not your petencies. At the end of the day, check your briefcase to see
boss or even your organization. It is the person you serve – if there is more in it than at the beginning of the day. If, day
an external or internal “customer.” As a litmus test of how after day, what you bring to work is the same as what
customer-focused you are, look back at your calendar for you take home, itʼs is time to move on to a more challeng-
the last week to find our how much actual time youʼve spent ing “assignment.”
with your external or internal customers. If you are not
spending at least one third of your time with your “cus-
tomers,” you are messing up.
Get in the habit of asking yourself,
64 The OR Connection
different people three out of five days a week, to sit with people
you donʼt know at meetings and to attend conferences that
are sponsored by groups other than yours.
Check yourself
To assess how well you are achieving a competitive advantage
in this tough economy, ask yourself the following diagnostic
questions:
ASK YOURSELF...
Am I learning?
If you are not constantly learning new things, your value in
• Am I learning?
the marketplace is diminishing rapidly. • Am I being taken advantage of?
Am I being taken advantage of?
• If my job was open today,
Your employer is taking advantage of you if you consistently would I get it?
sacrifice your long-term development to put out short-term
“fires.” Donʼt let your ego get the better of you when you are
• Am I adding value?
being told that you are so critical to the organization that “we • Am I good at selling?
canʼt do without you.” Hogwash! No one is indispensable.
Never, ever get caught in persistent short-term traps at the
• Am I energized by change?
expense of your long-term development. • Does my résumé focus
If my job was open today, would I get it?
on contributions?
Itʼs important that you “benchmark” your skills all of the time.
Continued on Page 36
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One way to do that is to look at the want ads to find out what liberate and empower you. Action will get you to grow,
the marketplace is looking for. If you do not possess the change and adapt. Action will provide you with virtual job
skills that the marketplace is looking for, itʼs time to invest security, will enable you to achieve the competitive advan-
more in yourself. tage and assure that you thrive in this tough economy.
Am I adding value?
How long does it take you to answer this question? If you
are unable to answer it immediately, in fewer than two or
three sentences, you can assume that no one else knows
how you contribute value either. In that case, you are a likely
target during the next downsizing.
Am I good at selling?
Many healthcare professionals see no need to become About the author
excellent at selling. The reality is that you sell all the time. Dr. Wolf J. Rinke, RD, CSP is a keynote speaker, seminar
You sell your patient on getting better, you sell your boss on leader, management consultant, executive coach and editor
a raise and you sell your team members on an idea. In of the free electronic newsletters Make It a Winning
addition, you do the same at home with your spouse, children Life and The Winning Manager. To subscribe, go to
and even your pets. Since it is something you do all of www.WolfRinke.com. He is the author of numerous books,
the time, I recommend that you get good at it. No, wait, I CDs and DVDs including Winning Management: 6 Fail-Safe
recommend you get great at it! So start looking for a quality Strategies for Building High-Performance Organizations and
sales program and attend it this year! Donʼt Oil the Squeaky Wheel and 19 Other Contrarian
Ways to Improve Your Leadership Effectiveness, available
Am I energized by change? at www.WolfRinke.com. His company also produces a wide
If you are still fighting or resisting change, you are in trouble. variety of quality pre-approved continuing professional
All indications are that change will continue to accelerate at education (CPE) self-study courses available at www.easy
“hyper speed,” so you might as well start welcoming it. CPEcredits.com. Reach him at WolfRinke@aol.com.
Angel hummed to herself as she tacked a poster on the the cause. She planned to reveal that at the meeting the
hospitalʼs bulletin board. She heard footsteps approaching next day.
and turned to see her coworker Mary peering over her shoulder
at the poster. Thanks to Angelʼs posters and word of mouth, the meeting
room was filled to capacity. True to her word, Mary arrived
“Whatʼs that, Angel?” Mary asked. “Itʼs pretty. I like the pink bearing a tray of cookies. At the podium in the front of the
ribbons. They match the ribbon on your lab coat!” room, Angel was nervously shuffling a stack of note cards.
She had written down what she planned to say, but as her
“Iʼm hosting a meeting for staff members to remind them how coworkers took their seats and started looking expectantly at
important it is to conduct monthly breast self-exams,” Angel her, she decided to place her notes in her pocket and simply
explained. “Can I count on you to be there?” speak from her heart.
“You bet!” Mary replied. “Iʼll even bring some cookies.” She “Hi, Iʼm Angel, and I know most of you,” she said. “You might
headed off down the hall to visit her next patient. have noticed that I spend a lot of time promoting education
about breast cancer, and encouraging you to do monthly self-
Angel smiled as she smoothed out the corners of the poster. exams. What you might not know is why I care so much.” She
She was known for tirelessly campaigning for breast cancer took a deep breath and steadied her voice.
education, but very few people knew what had drawn her to
68 The OR Connection
“When I was a sophomore in college, my mother was diag- “But thereʼs good news, too,” she continued. “Today, some-
nosed with breast cancer. I spent the next six months, what one who is diagnosed with breast cancer in its earliest stages
were ultimately the last six months of my motherʼs life, at her has a 98 percent chance of living. That rate was only 77
side. I was there when she was wheeled out of surgery after percent in 1982. And education is helping to emphasize the
a double mastectomy. I was there when chemo caused her importance of screening, early education and the need for
beautiful hair to fall out all over her pillow. And I was there more research.”
when she admitted to her doctor that she had never done a
breast self-exam. Angel grabbed for the stack of pamphlets she had brought
with her and began to hand them out. “These tell you how to
“My mother didnʼt know how to perform a self-exam, and she perform a breast self-exam and give you more information
wasnʼt comfortable with the idea. She didnʼt know that there on ways you can help spread the word,” she said. “Please,
could be outward signs of breast cancer, such as change in take a bunch of them! Give them to your friends, your family,
the size or shape of the nipple. She didnʼt know that dimpling your patients.” She was encouraged to see that the members
or puckering could be signs of an underlying problem. of the audience were taking four or fivepamphlets as they
were passed along.
“My mom didnʼt know these things, just as a lot of people
donʼt understand the full scope of how serious a problem She made her way back up to the front of the room to finish
breast cancer still is. Weʼre making advances in early detec- speaking. “Thank you so much for coming to this meeting. I
tion and treatment, but this disease is by no means going lost my mother to breast cancer, and Iʼll miss her every day
away. In fact, more than 1.1 million women throughout the of my life. With your help, though, we can prevent someone
world will be diagnosed with breast cancer this year, and else from experiencing that same agony. Education is truly
more than 410,000 of those women will die.” the key. Together, we can save lives through early detection.”
Angel looked around the room and saw that the faces of Angel smiled and was thrilled to see smiling faces looking
many audience members had turned grim. She needed to back at her.
inspire them, and fast!
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early detection of breast cancer and ultimately save lives. sales representative for more information.
The emotional and physical symptoms, which usually occur in the week or
two before your period, can range from mild to severe. Symptoms vary from
person to person and may include:
The cause of PMS remains unclear, but you may be able to ease symptoms
by following these self-care tips from the U.S. Department of Health and
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Lifestyle changes alone may not bring relief if you have severe symptoms.
If this is the case, your doctor may suggest an over-the-counter pain
reliever or other medicines.
72 The OR Connection
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FORMS & TOOLS
Electrosurgery
Electrosurgery Checklist..............................76
Electrosurgical Cautery Safety
Policy and Procedure ..................................78
Patient Safety
Surgical Safety Checklist........................86
Employee Safety
Management/Employee Checklist ..........89
Employee Incident Report ......................90
Electrosurgery Checklist
Preoperative Precautions and Procedures Do not overlap sections of the electrode (e.g., when
applying around a small limb).
Physical Condition When possible, place a long edge of the electrode
Examine the ESU and its accessories for defects— closest to the surgical site.
do not use cables or accessories with damaged If possible, do not place the dispersive electrode (or
(cracked, burned, or taped) insulation or connectors. active electrode) cables near internal pacemaker leads.
Confirm that the ESU has been inspected for safety
and performance by a qualified BMET or clinical Alternate Sites
engineer and that the next inspection is not yet due. Eliminate patient contact with grounded objects
whenever possible.
Return Electrode Contact Quality Monitor If possible, remove nonvital monitoring electrodes
(RECQM) or Cable Continuity Alarm (e.g., esophageal and rectal probes).
Check the operation of the RECQM or the return Keep ECG and other monitoring electrodes as far
electrode cable continuity alarm by attempting to as possible from the surgical site and the active and
operate the unit with the dispersive electrode dispersive electrode cables.
disconnected—the unit should not activate, and a Do not use needles as monitoring electrodes (these
tone should sound. increase the risk of alternate site burns due to higher
current density at the electrode site).
Audible Activation Indicator
Activate the unit using each footswitch and Prepping Agents
handswitch, and verify that the audible activation Avoid using flammable prepping agents or other
tone is loud enough to be heard over other noises in flammable fluids (e.g., acetone degreaser).
the OR. Avoid accumulating pools of fluids, especially near
Verify operation of any other alarms or patient electrodes.
protective features.
Sparking the Active Electrode
Safety Holster Do not spark the active electrode to ground or to the
Position a safety holster for the active electrode in a dispersive electrode to test the ESU.
convenient location.
Intraoperative Precautions and Procedures
Dispersive Electrode
Use a full-surface adhesive electrode. Minimize buildup of O2 and N2O beneath drapes and
Inspect the electrode before placement for any flaws in the oropharynx.
or damage (e.g., discoloration, insufficient amounts Activate the unit after vapors from flammable prepping
of conductive adhesive). solutions and tinctures (if used) have dissipated.
Confirm that the electrode's expiration date has Activate the unit only when ready to deliver electrosur-
not passed. gical current and only when the active tip is in view;
Clean, shave, and dry the application site. avoid prolonged activation.
Follow the manufacturer's recommendations for appli- Use the lowest effective ESU output setting; do not
cation, and ensure firm contact of the electrode with continue to increase power settings if you aren't
the skin. getting results—look for other problems (e.g., confirm
Do not apply the electrode to areas where pressure is adequate placement of the dispersive electrode,
applied to the patient (e.g., underneath the patient). check all cable connections).
76 The OR Connection
Electrosurgery Checklist 1 Forms & Tools
Inspect the patient for injuries at the dispersive Gawande says there's been some resistance to the
electrode and other sites (e.g., the sacral area— list. One London surgeon thought it was demeaning
electrosurgical injuries typically appear immediately "Mickey Mouse stuff" until one day in the operat-
following the procedure; pressure injuries may not ing room.
show up for as long as one or two days following
surgery). "Right before the incision [the medical team] took a
Document all findings. timeout," Gawande says, "and when it came to the
If any problems are noted during or after the nurse's turn to raise any concerns, the nurse asked:
procedure, save all disposable items and their
'Are we really sure we have the right size knee
packages (so that expiration dates can be confirmed).
replacement for this patient?'"
Turns out, they didn't — not anywhere in the hospital.
Courtesy of Medical Device Safety Report (MDSR) ECRI Institute, 2008.
That surgeon now swears by the surgical checklist.
78 The OR Connection
Policy and Procedure Forms & Tools
The Electrosurgical Active Electrode (Pencil): Based upon the policy and procedure used at Stonewall
– Only electrosurgical active electrodes approved by Jackson Memorial Hospital in Lewis County, West Virginia.
the hospital Biomedical Engineer are to be used in
the Surgical Services Department.
– The active electrode shall be inspected at the field
for damage before each use.
– The active electrode shall fasten directly into a
labeled, stress-resistant receptacle on the
electrosurgical unit.
– The active electrode cord shall be long enough
and flexible enough to reach the operative site and
the generator without stress.
– The active electrode cord shall be free of loops,
twists and metal clamps that can deviate
current flow.
– The active electrode and cord shall be inpervious
to fluids.
– The active electrode tip shall be secure and free of
charred tissue. Use a moist sponge to clean
the tip.
– The active electrode will be placed in a holster at
all times, when not in use.
www.medline.com
Pressure Ulcer Prevention Policy and Procedure Forms & Tools
Early and ongoing assessment of patients at risk for skin breakdown is essential.
Prevention involves not only identification of patients at risk but also a detailed plan
of interventions which address and minimize the effects of each risk factor.
Nursing Diagnosis
1. Identify patients at risk for developing a 1. Determine an adult patient's risk for
pressure ulcer upon admission and daily for developing a pressure ulcer by using the
at-risk patients or with any change in condition. Braden Risk Assessment.
A patient is considered at risk if their
Braden score is:
15-18 = Mild risk
13-14 = Moderate risk
10-12 = High risk
9 or below = Very high risk
2. Advance your patient to the next risk level in
the presence of:
A. Age over 75
B. Chronic illness
C. Hemodynamic instability (e.g., diastolic
blood pressure less than 60 mmHg).
3. Utilize the Nursing Care Plan to individualize
specific prevention interventions.
4. Initiate Pressure Ulcer Treatment Protocol at
the first sign of skin breakdown.
5. Consult WOC nurse when current plan of
care does not meet the needs of the patient.
2. Assess specific vulnerable pressure points. 2. Inspect the skin at least every 8 hours.
A. Supine: occiput, sacrum, heels A. Avoid vigorous massage over bony
B. Sitting: ischial tuberosities, coccyx prominences.
C. Side-lying position: trochanters B. Patients with dark pigmentation will
D. Reddened areas which do not fade within demonstrate a cyanotic area, warmth or
30 minutes complain of pain over the bony prominence.
E. Dusky or cyanotic areas
F. Under devices (i.e., TEDs, pneumoboots,
splints, collars, tubing)
3. Assess skin for exposure to moisture from 3. Cleanse and dry skin at routine intervals or
intervals incontinence, wound drainage and at the time of soiling, using a low residue soap.
perspiration. A. Initiate the Incontinence Protocol in the
incontinent patient.
B. Moisturize dry skin with lotion.
82 The OR Connection
Pressure Ulcer Prevention Policy and Procedure Forms & Tools
Nursing Diagnosis
4. A. Assess mobility and activity status. 4. A. 1. Maintain or increase patient's level of
activity, mobility and range of motion unless
B. Identify sitting status. contraindicated.
2. Schedule regular and frequent turning and
repositioning at least every 2 hours (e.g.,
alternating supine, left lateral and right lateral
positions).
3. Individualize to the patient's needs based
on risk and level of mobility.
B. For sitting position in bed (head of bed
greater than 30°), cardiac chair or wheelchair:
1. Assist/instruct patient to shift weight at
least every 15 minutes.
2. Reposition at least every 30 minutes if
patient cannot independently perform
pressure relief exercises every 15 minutes.
3. Consult PT/OT for assistance in seating,
positioning and wheelchair cushion options.
6. Identify factors that increase shearing, fric- 6. A. 1. Keep head of bed less than 30° unless
tion and/or pressure. contraindicated.
A. Shearing: Tissue layers sliding against each 2. Promote proper positioning, transferring and
other; e.g., sliding down in bed. turning techniques.
B. Friction: Skin rubbing against other sur- B. 1. Use reusable underpad, trapeze or lift
faces; e.g., elbows and heels rubbing against sheet to lift, not drag, patient.
sheets. 2. Utilize pillows or positioning devices to
C. Pressure/friction: e.g., heels resting on mat- prevent skin surfaces from rubbing together.
tress, devices such as oxygen tubing, cervical C. 1. The immobilized patient should have heels
collars, casts. suspended off bed by using pillows or heel
suspension boots.
2. Heel and elbow protectors are best used for
reducing friction and should not be used for
pressure reduction.
3. Pad devices when it is not contraindicated.
Nursing Diagnosis
7. Assess patient/family knowledge of pressure 7. A. Teach patient/family about the causes and
ulcer prevention, risk factors and early treatment. risk factors for pressure ulcer development and
ways to minimize risk.
B. The patient or caregiver, or both, should
understand the importance of the following:
1. Conduct regular inspection of skin over bony
prominences. (Individuals can use a mirror if
necessary to inspect their own skin.)
2. Follow appropriate skincare regimens.
3. Use measures to reduce friction/shearing.
4. Avoid vigorous massage of bony prominences
or reddened area.
5. Include routine turning, repositioning and the
use of pressure-reducing devices if patient is
confined to bed and/or chair.
6. Avoid use of donut-type devices.
7. Maintain adequate nutrition and fluid intake
and monitoring for weight loss, poor appetite or
gastrointestinal changes that interfere with eating.
8. Program for bowel and bladder management.
9. Promptly report healthcare changes and
nutritional problems to healthcare providers.
Adapted from North Memorial Health Care’s Pressure Ulcer Prevention Protocol.
References
Bryant R. Acute and Chronic Wounds. 2nd ed. St. Louis: Mosby; 2000.
Frantz RA. Evidence-based protocol: Prevention of pressure ulcers. Journal of Gerontological Nursing. 2004;30(2):4-11.
Hobbs BK. (2004). Reducing the incidence of pressure ulcers: Implementation of a turn-team nursing program. Journal of
Gerontological Nursing. 2004;30(11):46-51.
Makelbust J, Sieggreen M. Pressure Ulcers: Guidelines for Prevention and Management. 3rd ed. Pennsylvania:
Springhouse; 2001.
Wound, Ostomy and Continence Nurses Society. Guidelines for the Prevention and Management of Pressure Ulcers.
Glenview, Ill; 2003.
U.S. Department of Health and Human Services. Pressure ulcers in adults: Prediction and prevention clinical practice
guideline. 1992.
84 The OR Connection
Forms & Tools Policy Sample
86 The OR Connection
Meets CDC 03’ and
05’ guidelines for
environmental and
TB infection controls
* The CDC recommends the use of anterooms above other air cleaning technologies.
Level-4 Gown
Is there demonstrated organizational concern for Is there tracking, trending, and regular reporting on
employee emotional and physical safety and health violent incidents through the safety committee?
as well as that of the patients?
Are front-line workers included as regular members
Is there a written workplace violence prevention and participants in the safety committee as well as
program in your facility? violence tracking activities?
Did front-line workers as well as management Does the tracking and reporting capture all types of
participate in developing the plan? violence— fatalities, physical assaults, harassment,
aggressive behavior, threats, verbal abuse, and
Is there someone clearly responsible for the violence sexual assaults?
prevention program to ensure that all managers,
supervisors, and employees understand Does the tracking and reporting system use the latest
their obligations? categories of violence so data can be compared?
Do those responsible have sufficient authority and Have the high-risk locations or jobs with the greatest
resources to take all action necessary to ensure risk of violence as well as the processes and procedures
worker safety? that put employees at risk been identified?
Does the violence prevention program address Is there a root-cause analysis of the risk factors
the kinds of violent incidents that are occurring in associated with individual violent incidents so that
your facility? current response systems can be addressed and
hazards can be eliminated and corrected?
Does the program provide for post-assault medical
treatment and psychological counseling for healthcare Are employees consulted about what corrective
workers who experience or witness assaults or actions need to be taken for single incidents or
violence incidents? surveyed about violence concerns in general?
Is there a system to notify employees promptly about Is there follow-up of employees involved in or witnessing
specific workplace security hazards or threats that are violent incidents to assure that appropriate medical
made? Are employees aware of this system? treatment and counseling have been provided?
Is there a system for employees to inform management Has a process for reporting violent incidents within the
about workplace security hazards or threats without facility to the police or requesting police assistance
fear of reprisal? Are employees aware of this system? been established?
Is there a system for employees to promptly report Source: U.S. Department of Labor. Guidelines for Preventing Work-
place Violence for Health Care & Social Service Workers. Available
violent incidents, "near misses," threats, and verbal at: http://www.osha.gov/Publications/OSHA3148/osha3148.html. Ac-
assaults without fear of reprisal? cessed June 19, 2008.
________________________________________________________________________________________________
❑ Assaults or Violent Acts: ____ Type "l"____ Type "2"____ Type "3"____ Other____
(For each person, complete a report; however, to the extent facts are duplicative,
any person's report may incorporate another person's report.)
Third parties or non-employee involvement (include contractor and lease employees, visitors, vendors, customers)? ❑ Yes ❑ No
90 The OR Connection
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